HOSPITAL INQUIRY

Manawatu Standard, Volume LIV, Issue 304, 21 November 1934, Page 9

HOSPITAL INQUIRY

INTO DEATH OF CHILD. COMPLAINT BY PARENTS. Per Press Association. AUCKLAND, Nov. 20. An investigation into complaints by Mr G. A. Downie, of Remuera, that his son Kenneth, aged 85 years, who died in the Auckland Hospital on October 17, was not seen by an honorary consulting specialist and did not receive prompt treatment, was commenced t>y the house committee of the Auckland Hospital Board to-night. Mr and Airs Downie were present in addition to the hospital othcers concerned. The case was mentioned at the meeting of the board in the afternoon.

“\Y r e have nothing to hide in this matter,” said the ciiairman (Mr W. Wallace), “and we want to get to the bottom of it. Statements have been prepared by the officers and probably the complaint may not be as serious as it appears. I think we should refer the matter to the house committee to investigate and invite the Press to be present. Definite instructions were given some time ago by the medical superintendent (Dr. Craven) that the resident medical officer in charge should report to the honorary consultant concerned as soon as possible in such a case as this. I understand that, on the day in question, the member of the honorary staff who should have seen this boy was actually in the grounds of the hospital.’’ When the inquiry opened to-night Dr. Pezaro, who ordered the child to hospital on October 15, was unable to attend, but wrote intimating that he would be available personally at a later date.

A letter written by Air Downie to Dr. Craven, setting forth the grounds of his complaint, was read to the committee. Mr Downie said the child had been admitted as an urgent case for an immediate blood transfusion. This had been performed 24 hours after admission and then only by a junior doctor on the resident staff. The honorary consultant in charge of the case had never seen the boy. He also complained about delays at the admitting office and in the taking of blood tests of his wife and himseif for the purpose of a blood transfusion. Air Wood said the best course for the committee to follow would be to hear the written reports of the doctrs and nurses in answer to the points raised in Air Downie’s complaint. STATEMENTS BY DOCTORS. In a letter to the board Dr. Pezaro outlined the boy’s illness. He went to the hospital and saw the assistantmedical superintendent (Dr. Gould) to explain the case and arrange for the boy’s admission. “In my opinion,” Dr. Pezaro added, “the boy’s condition was extremely grave from the moment I saw him and I was not surprised to heard of his death.”

Dr. Gould reported that Dr. Pezaro had spoken to him in reference to the case. He gave the usual instructions to the admitting office —that the patient was to be admitted immediately. Dr. Pezaro had said the child was very ill and might even need a blood transfusion. In his statement to the board, Dr. E. S. Jamieson, the resident doctor concerned in the case, said Kenneth Downie was admitted to his ward at 2.30 p.m. and put in cot 15. “I found a note from the boy’s doctor on his chart,” Dr Jamieson continued. “It read, ‘Please admit, as arranged, Kenneth Downie, severe anaemia.’ An examination revealed two main features—severe anaemia, with a very low blood count, and a very weak and exhausted heart. “Treatment was the next consideration, and a blood transfusion was required. The blood transfusion was postponed for three reasons-—the laboratory had closed at 4.30 p.m., so that bloodtyping was not possible until the following day. In my opinion the boy’s condition did not warrant my employing a universal donor, with the risk attached to that/and the boy’s heart was in such a condition that an immediate transfusion would have severely hampered his slender chance of life. For these reasons the transfusion was postponed until the following day. “That evening I went to telephone the office and gave instructions for the parents to be at the laboratory at 9 a.m. to be typed the following morning. I arranged for the theatre to be ready at 2 p.m. for the transfusion, this being the earliest and most convenient hour available. The operation began at 2.30 p.m. and was successfully completed, the parents remarking that the boy looked better already. “I saw him in the afternoon and several times in the evening. His condition was becoming worse and I prescribed alleviating treatments and left instructions with the nursing staff before retiring. I saw him again at 3.45 a.m. and remained with him until 5 a.m. He wa9 so obviously worse that 1 telephoned my honorary, who approved of my treatment and could suggest nothing further to be done.” OPINION OF HONORARY STAFF AIEAIBER. “I attended the post-mortem examination,” said Dr. Ludbrook, a member of the honorary staff, “and discussed the treatment with Dr. Jamieson. The boy’s condition was so serious on admission that he thought it advisable to delay the blood transfusion. With this decision I entirely agree. When, after the transfusion, the condition of the child became worse, Dr. Jamieson carried out all possible methods of treatment for such a condition. In my opinion the treatment of this boy was carried out with the best possible skill and no other treatment could have saved the boy’s life, for the disease he was suffering from was such that there was no possible hope of recovery.”

Sister I. M. Reynolds, wlio was in charge of the ward on the afternoon of October 15, said in her written statement that she did not remember seeing Mrs Downie or the boy until the latter was in bed in the ward. Had she seen the boy, who looked • very ill, she would have put him on a bed and sent the mother to the admitting oliice for the necessary forms. “I was off duty the following afternoon when the blood transfusion was given, but I came on at 6 p.m. The child’s condition then was serious. Mrs Downie came between 7 and 7.30 p.m. and said she thought the child was worse. I told her he was serious and she replied, ‘I know, but I can’t do any good sitting there and I’m going to the pictures. If there is any message the neighbours will put a note under the doormat and I will get it on my return homo.’ I was so taken aback I could scarcely reply for a minute and then I said, ‘You do realise the child is seriously ill?” to which she replied, ‘Oh! yes; I know’.” The night • superintenednt (Sister Hart) said the child had been visited frequently by the doctors and nurses during the night. She considered Mr Downie’s accusation of negligence was unwarranted. CRUX OF COMPLAINT.

After the letters had been read, Mr Downie said he wished it to be understood from the outset that he was not attacking the case on purely medical grounds. “The crux of my complaint is that

a specialist was not called in,” Mi' Downie continued. “Even though Dr. Ludbrook says he would not have altered the treatment given by Hr. Jamieson that does not alter the position. It is only natural for one professional man to cover up another.” Air Howitt: That is an unfair statement—to say that one doctor is covering up another’s mistake. “I am not criticising the treatment given by Dr. Jamieson,” Air Downie replied. “His mistake was that Dr. Ludbrook was never notified. He is a specialist—a first-class man on his job—and his services should have been available. Dr, Pezaro told me when he ordered the boy to the hospital that he had a 50-50 chance. I say that, when he came here, his chance was gone —evaporated.” Amplifying his written statement, Dr. Gould said Dr. Pezaro had made no suggestion to him about performing an immediate blood transfusion. Mr Wallace: Is it usual for a medical practitioner to order the treatment which a patient shall get in the hospital ? Dr. Gould: No.

Air Wallace: Knowing it was a very serious case, do you not think you should have seen the child ? Dr. Gould : We have so many serious cases. I gave instructions for the child to be admitted immediately and, if necessary, I could have been called to the ward. Dr. Ludbrook said there was very little lie could add to his report. Air Wood: You have noted the complaint that the child was not seen by an expert? Dr. Ludbrook: I did not see the child at all. I can give no opinion, except that, from the records of the case, I think Dr. Jamieson was quite right in postponing the blood transfusion.

SERIES OF QUESTIONS. BY BOARD CHAIRAIAN. Per Press Association. AUCKLAND, Nov. 21. The inquiry by the Hospital Board committee into the treatment of the child Kenneth Downie was not finished last night, and will be continued this afternoon. Questioned by the chairman of the board (Air W. Wallace), Dr. Jamieson said he did not consider a patient in the ward was in his charge. Air Wallace: Then whose,? Dr. Jamieson: The honorary concerned. Air Wallace. How can the honorary know a patient is there if he is not informed ? Dr. Jamieson: I do not know. Dr. Jamieson added that ho usually telephoned his honorary when a serious case name in. He could not explain why he did not do it in this case. Questioned by the boy’s father, Dr. Ludbrook (the honorary) said that on the day the boy was admitted he was twice in the hospital, though not in the children’s ward. Dr. Pezaro was probably not aware of the true diagnosis when be sent the boy to the hospital; that came out only in the post-mortem, which showed that the boy bad no chance of living. On the evidence before him he could not have suggested any other treatment than what Dr. Jamieson gave. In further evidence, the chairman said the mother could have stayed with the boy in the ward all night if she bad wished. No objection was ever raised to that in a serious case.

Airs Downie: If I bad known that I would have stayed. It was my first experience of a hospital and 1 am always horrified of getting in the way. I thought the visiting hours were strict.

Before the adjournment, Air Downie thanked the committee 'for its courtesy and said the superintendent had done everything possible for him.